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Substance Withdrawal Substance withdrawal, as used in DSM-IV, is a diagnostic term rather than atechnical term. Thus minor symptoms that technically are due to cessation of substance use (e.g., thecoffee drinker's early morning precoffee lethargy or minor headache) would not by themselves fulfill thecriteria for substance withdrawal, unless they are accompanied by a maladaptive behavior change andcause some clinically significant distress or impairment in social, occupational, or other important areaof functioning. DSM-IV does not recognize withdrawal from caffeine, cannabis, or PCP, although someobservers believe that specific signs and symptoms can be observed when those agents are abruptlydiscontinued after a period of heavy use. ICD-10 does describe a cannabinoid withdrawal state.Withdrawal is commonly, but not invariably, associated with substance dependence. The signs andsymptoms of withdrawal vary with the specific class of drug. In general, the severity of withdrawal isrelated to the amount of substance used and the duration and patterns of use. Withdrawal is seen not onlywhen substance use is stopped but also when reduced use of a substance or a change in metabolismresults in lower tissue levels. The DSM-IV generic criteria for substance withdrawal are shown in Table11.1-9; the ICD-10 general criteria are shown in Table 11.1-4. Specific diagnostic criteria for withdrawalfrom each category of drugs, to be used when the general criteria have been met, are also provided.Table 11.1-9 DSM-IV Diagnostic Criteria for SubstanceWithdrawalSubstance Intoxication Substance intoxication is defined more narrowly in DSM-IV than it might be ina pharmacology text. A variety of substances may produce unwanted physiological or psychologicaleffects that could be construed as substance intoxication effects (e.g., excessive sleepiness following useof an antihistamine), but unless the symptoms are associated with maladaptive behavior, the effectswould not constitute substance-induced intoxication as defined in DSM-IV. Furthermore, whether abehavioral effect is maladaptive depends on the social and environmental context in which it occurs. Ifalcohol makes a person unusually sociable, a bit garrulous, and a little uncoordinated at a familycelebration this is probably not maladaptive drinking behavior, the same behavior at a formal businessmeeting probably is. Similarly, ICD-10 specifies that intoxication must produce disturbances in the levelof consciousness, cognition, perception, affect, or behavior that are of clinical importance. However, itrequests clinicians to further specify which of several common complications of intoxication (e.g.,trauma, delirium, convulsions) are also present. The DSM-IV general criteria for substance intoxicationare shown in Table 11.1-10. In addition, ICD-10 provides specific sets of diagnostic criteria for each ofthe drug categories and for multiple drugs, to be used once the generic criteria for intoxication have been

met. Also shown are the additional specifiers for complications of intoxication (Table 11.1-4).Table 11.1-10 DSM-IV Diagnostic Criteria for SubstanceIntoxicationSubstance-Induced Disorders In addition to dependence, abuse, intoxication, and withdrawal, the useof certain psychoactive drugs can induce syndromes that used to be called organic mental disorders. Toavoid implying that other psychiatric disorders do not have an organic basis, DSM-IV designates thesesyndromes substance-induced disorders and recognizes the following categories: substance intoxication,substance withdrawal, substance-induced withdrawal delirium, substance-induced intoxication delirium,substance-induced persisting dementia, substance-induced persisting amnestic disorder, substanceinduced mood disorder, substance-induced anxiety disorder, substance-induced psychotic disorder,substance-induced sexual dysfunction, and substance-induced sleep disorder.In recording a diagnosis of a substance-related disorder, the clinician should indicate the specific agentcausing the disorder, if known, rather than the broad drug category; that is, substance-inducedintoxication, pentobarbital (Nembutal) rather than substance-induced intoxication, sedative-hypnotics.However, the diagnostic code should be selected from the list of classes of substances provided in sets ofcriteria for the substance-induced disorder being recorded. For each of the substance-induced disorders(other than intoxication and withdrawal), the clinician is asked to specify whether the onset was duringintoxication or during withdrawal. Thus, a specific substance-induced disorder would have a three-partname delineating (1) the specific substance, (2) the context (whether the disorder occurred duringintoxication or during withdrawal or occurs or persists beyond those stages), and (3) thephenomenological presentation (e.g., diazepam [Valium]-induced anxiety disorder with onset duringwithdrawal).Table 11.1-11 shows the various disorders induced by the major categories of substances recognized byDSM-IV and indicates which disorders are seen during intoxication and during withdrawal. Althoughthey are not included specifically in the table, anabolic-adrenergic steroids can also induce psychoticmood, anxiety, and sleep and sexual disorders, and their withdrawal can also be associated with moodand sleep disorders. ICD-10 has a distinctly different approach to recording these drug-related disorders.With the first and second digits after the letter committed to designating the drug category, additionalpsychiatric syndromes are indicated by the use of the third and fourth digits. For example, persistentmood disorder associated with hallucinogens is designated F16.72. For the diagnosis to be made, themood disorder would need to meet the criteria listed for mood (affective) disorders.

Table 11.1-11 DSM-IV Diagnoses Associated With Class ofSubstancesEvolving Terminology The terminology used to describe the substance-related disorders has beenrepeatedly revised as concepts about the nature of drug-using behavior have evolved. In the 1980 thirdedition of the DSM (DSM-III) drug use disorders were divided into two major categories, drug abuseand drug dependence, and specific criteria for diagnosis were given. In DSM-III-R, adopted in 1987, thetwo categories were retained, but the diagnostic criteria were modified. Further revisions were made forDSM-IV, which adopted the terms “substance abuse” and “substance dependence,” probably toeliminate the use of the more cumbersome term “alcohol and drug dependence including tobacco.” Forsimilar reasons, ICD-10 adopted the term “psychoactive substance dependence.”In much of the world literature on drug dependence, the term “dependence” is used to convey twodistinct ideas: (1) a behavioral syndrome and (2) physical or physiological dependence. Physiologicaldependence can be defined as an alteration in neural systems that is manifested by tolerance and theappearance of withdrawal phenomena when a chronically administered drug is discontinued or displacedfrom its receptor. Because the dual use of the word causes confusion, the 1980 ADAMHA-WHOworking group recommended restricting use of the term “dependence” to describe the behavioralsyndrome and substituting the term “neuroadaptation” for physical dependence. Such a substitutionwould have emphasized several points. First, the continued use of many drugs, including tricyclicantidepressants and β-adrenergic receptor antagonists, causes neuroadaptive changes followed bywithdrawal phenomena, but not by drug-seeking behavior, on their discontinuation. Second,neuroadaptive changes begin with the first dose of an opioid or sedative drug, and therefore, suchchanges in and of themselves are not a sufficient cause (or definition) of drug dependence as abehavioral syndrome.Why Use “Addiction”? The words “addict” and “addiction” often have pejorative connotations; theyare also frequently trivialized and used to refer to ordinary activities, such as exercising and solvingcrossword puzzles. However, the term “addiction” continues to have the core connotation of decreasedcontrol, and some chapters in this book have retained such terms as “opioid addict” because they are lessawkward to use than terms such as “severely opioid-dependent person” when referring to persons whoare dependent on drugs to a severe degree. Here the word “dependent,” unmodified, is used to meanbehaviorally dependent. The term “physiological dependence” or “physical dependence” is used to referto the physiological changes that result in withdrawal symptoms when drugs are discontinued.

COMPARATIVE NOSOLOGYDSM-IV and ICD-10 The generic concept of dependence is virtually identical in DSM-IV and ICD-10.By requiring the clinician to specify whether tolerance and withdrawal are present, DSM-IV appears torecognize a special significance for tolerance and physiological dependence. Some data indicate thatamong alcoholics the presence of physical dependence and, to a lesser degree, tolerance is associatedwith a more severe variety of the syndrome. In practice, however, requiring evidence of these criteriawould not substantially reduce the number of cases meeting the criteria for dependence in most drugcategories, with the exception of hallucinogens, a class of drugs for which DSM-IV does not listphysiological dependence as a criterion. There is generally a high level of agreement between DSM-IVand ICD-10 for making a diagnosis of dependence, although the descriptions of the criteria fordetermining the presence and severity of the syndrome differ. They both require that three elements ofthe syndrome have been present in a 12-month period. The DSM-IV categorization of drug classesdiffers somewhat from the one used by ICD-10, which, constrained by a new alphanumeric system, usesonly nine drug categories by including caffeine with amphetamine-like stimulants and PCP with otherpsychoactive agents.The word “abuse” is also commonly used in ways that differ significantly from the definitions developedfor use in DSM-IV. In popular and legislative contexts drug abuse means any use of an illicit substanceor any nonprescribed use of a drug intended as a medicine, as well as the harmful or excessive use oflegally available substances, such as alcohol and tobacco.Despite the reliability of DSM-IV and ICD-10 criteria for dependence in many European and AngloAmerican cultures, several criteria (e.g., narrowing of drinking repertoire, time spent obtaining the drug,and even tolerance for the drug) have posed difficulties in other cultures, especially when dealing withalcohol. Tolerance is often understood when applied to drugs, but not to alcohol; in some cultures,holding one's liquor is a sign of manhood. Clinicians are more likely to make a diagnosis of drugdependence than alcohol dependence even when behavioral signs are comparable. In several cultures,little or no distinction is recognized between use, abuse, and harmful use of illicit drugs.Other Perspectives The criteria for diagnosis in DSM-IV and ICD-10 were developed from what isessentially a biopsychosocial model of substance dependence. In such a model multiple factors—genetic, psychological, sociological, and pharmacological—contribute to the observed clinicalsyndromes. Such apparent unanimity about drug dependence should not obscure the existence ofdissenting perspectives, which take several forms. In one the biopsychosocial model is accused of givingtoo much weight to biological factors and too little recognition to the notion of human will andresponsibility, of medicalizing deviant behavior for the benefit of treatment professionals, and ofcreating universal exculpation for all those who fail to live up to reasonable societal expectations. Butsome professionals have implicitly criticized the same biopsychosocial model for not giving sufficientweight to the ideas that substance dependence is a specific primary disease (i.e., not a symptom of otherpsychiatric difficulties), that those who develop the disease have no control over their intake of certain

substances, and that denial of the presence of a problem is a major characteristic of the disease.Concepts about substance dependence can be arrayed along several dimensions that are not entirelyindependent or orthogonal: broad versus narrow, disease versus learned behavior, and social versusmedical. The narrow concept of substance dependence accepts as disorders those maladaptive behaviorsassociated primarily, if not exclusively, with the ingestion of substances generally accepted aspharmacological agents. Compulsive eating, gambling, running, hair pulling, and repetitive excessivesexual activities are not included among the dependence disorders, although those problems may sharecertain features that resemble a decreased ability to choose and are sometimes ameliorated byparticipation in support groups founded on principles similar to those of Alcoholics Anonymous (AA).A broad approach would create a superclass of disorders that would include a number of such behaviorsnot involving pharmacological agents.At the disease end of the disease-versus-behavioral syndrome dimension is a belief that dependence isnot a learned behavior that can be modified or ameliorated with relearning but is a primary disordercaused by an interaction between a substance and a person with some genetic vulnerability and that onlytotal abstinence can arrest the progression of the disease. The medical-versus-social dimension typicallydescribes a range of views on how best to respond to problems with substances, rather than differencesabout the essential nature of the problems. The medical model stresses issues of assessment—treatment,planning, and record keeping—and sometimes treatment that can be rendered only by those withprofessional training (not necessarily physicians). The social model emphasizes the importance of socialsupports and integrating the person with a problem into a network of recovering persons who can offercontinuing support. The assessment and recording of progress and outcome as generally practiced bycredentialed professionals is minimized.HISTORYThe most commonly abused drugs have been in use for hundreds, if not thousands, of years. Forexample, opium has been used for medicinal purposes for at least 3500 years, references to cannabis(marijuana) as medicinal can be found in ancient Chinese herbals, and wine is mentioned frequently inthe Bible. The indigenous people of the Western Hemisphere were smoking tobacco and chewing cocaleaves generations before the arrival of the Spaniards. Some of the problems caused by alcohol and otherdrugs, such as drunkenness, are described in the Bible and in the writings of the ancient Greeks andRomans. As new and more concentrated forms of drugs were discovered or invented or new routes ofadministering them were developed, new problems related to their use emerged. For instance, whencheap gin was introduced into England in the eighteenth century, the alcohol-related problems thatemerged were considered more serious than those associated with beer and wine. Although opiumsmoking was a major problem in Asia in the eighteenth and nineteenth centuries, new problems wereseen after morphine, the most active opium alkaloid, was isolated in 1806. Morphine was subject tomisuse by injection from the late nineteenth century on, and intravenous morphine and heroin use beganto spread in the early part of the twentieth century. Tobacco use and its associated problems did notbecome widespread until the nineteenth century, when new methods of curing the leaves produced a

mild smoking tobacco and cigarettes were introduced, which made common the practice of inhalingtobacco smoke deeply into the lungs. By the early twentieth century, cigarette smoking was a popularpractice.Medicalizing Excessive Drug Use In 1810 Benjamin Rush, who is often credited as the first Americanphysician to suggest that excessive use of alcohol was a disease rather than exclusively a moral defect,proposed the establishment of a sober house; in 1835 Samuel Woodward, a pioneer in the establishmentof asylums for the insane, advocated similar asylums for inebriates. Contemporaneous with those earlymoves to involve medicine in dealing with excessive alcohol use was the emergence of the temperancemovement and the Washingtonians—groups of reformed drunkards concerned with helping others toadopt and maintain sobriety. In the process the Washingtonians developed many of the principles of selfhelp that were rediscovered by AA almost a century later. When the ideas of voluntarism and self-helpas exemplified by Washingtonian societies failed to eliminate the problem of drunkenness, physiciansbegan to debate more seriously the idea of coerced treatment in inebriate asylums supported by publicfunds. In 1870 advocates of the approach established the American Association for the Cure ofInebriates (AACI), dedicated to setting up hospitals for such persons, conducting research, and teachingmedical students and physicians how to treat inebriety. At first those physicians who believed in a morespiritual, voluntary approach to the problem (neo-Washingtonians) were part of the AACI, but graduallythe more somatically oriented factions, which advocated medically supervised asylums (and compulsorytreatment when needed), gained ascendancy. Furthermore, the focus of concern was no longer limited tothose who abused alcohol. Thomas Crothers, the secretary of AACI, saw inebriate asylums as places totreat all those who used any variety of intoxicant or narcotic to excess. However, very few publiclysupported inebriate asylums ever opened.Early Attitudes The closing years of the nineteenth century saw growing concern about the excessiveand inappropriate use of drugs, including alcohol and tobacco as well as opiates and cocaine. Firstisolated from the coca leaf in 1860, cocaine came into widespread use in 1885 when pharmaceuticalcompanies began selling it in the United States and Europe. In 1884 Sigmund Freud had published areview of the potential therapeutic uses of cocaine. Some medical authorities in the United States sharedhis enthusiasm, and cocaine was recommended

arrest or marital arguments is not in itself evidence of harmful use.” Four diagnostic criteria must be met to make the ICD-10 diagnosis of harmful use. Substance Withdrawal Substance withdrawal, as used in DSM-IV, is a diagnostic term rather than a technical term. Thus minor symptoms that